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Dr. Andrew Rynne

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What does my MRI scan report indicate?

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Dr. Sagar Makode

Cardiologist

Practicing since :2013

Answered : 1717 Questions

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Posted on Wed, 15 Mar 2017 in Hypertension and Heart Disease
Question: Hello- I am a GP practicing in Australia. My wife has recently been diagnosed with mitral valve insufficiency and grade 2-3 mitral regurgitation. She is also experiencing frequent ectopic beats- some lasting 5 secondsShe has always had very low BP her whole life-usually runs at 110/58. She has had an MRI of cervical spine to level of T2-all normal. She has had a brain scan - all normal. Had an angiogram- no blockages whatsoever.
Her symptomatology is weakness, loss of strength, heart flutter, dizziness AND partial numbness of both arms and hands - approx. 20% numb .
Her heart specialist has put her on beta blockers which has helped the veb's and she feels better but when she does minor exercise such as walking to the end of the hallway and back the tingles and weakness get worse.
I asked why not put in a pacemaker-he said- not going to help the problem. Today he suggested putting her on "piroxetene" an antidepressant- which is an insult as far as I'm concerned.
Since being on the beta blockers her heart rate has dropped to 37 -45 and her normally low BP has also dropped.
The specialist states UNEQUIVICLLY that the partial numbness cannot be from the loe BP, low heart rate , mitral insufficiency and the frequent VEB's.
Can you please give me your opinion concerning the beta blockers, the pacemaker and the partial numbness situation. As you can imagine I'm a little over my head and need some direction.
Thanks, Dr. Roy Gillrie
doctor
Answered by Dr. Sagar Makode 54 minutes later
Brief Answer:
See the description

Detailed Answer:
hello,
First what's the cause for ectopics, is there a ventricular dysfunction like low ef or dilatation of heart etc. If it's there, she ll be a candidate for surgery, if not then we need to manage her on medicine. Then we need to get some more test like thyroid, serum magnesium and calcium, potassium, which I guess must have been done.
Regarding, symptoms, low blood pressure and pulse rate can certainly cause dizziness, fainting, weakness. Regarding, numbness, tingling, it can occur with low bp and pulse rate in some patients, especially if it increases with sudden getting up or walking and tend to be associated with other symptoms of low bp like weakness and dizziness. Also, we have already ruled out other causes like cervical. Neuropathic tingling and numbness would be persistent, fixed and not change with posture, walking, it would be especially occurs in glove and stockings distribution etc. So I think it's a symptom of low bp.
Next thing, regarding its treatment, beta blockers is treatment of choice. I need to know that dose she is taking. Heart rate you mentioned is certainly low, so I think we should try reducing the dose especially if she has responded to beta blockers and ectopics have resolved. Also, you mentioned that they persist for 5 seconds. Has she undergone holter just to rule out are there any episodes of non sustained ventricular tachycardia. If not she should once undergo it. Now, next option is another antiarrhythmic like flecainide or amiodarone depending upon her echo parameters, especially if we are not able to continue beta blockers because of low bp and ectopics are not controlled.
Pacemaker has not got any role in ectopics, and here low heart rate is probably due to beta blockers so decreasing the dose will normalise the pulse rate. I guess you didn't mean ICD device, and she is also not a candidate for it as she didn't have any episodes of ventricular tachycardia or fibrillation or other serious issues. It is also indicated in patients with low ejection fraction say less than 35%.
So I guess that resolves your doubts, feel free to ask if I am not able to clarify.
Above answer was peer-reviewed by : Dr. Remy Koshy
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Follow up: Dr. Sagar Makode 57 minutes later
Dr. Makonde- thank you for the quick detailed response. Here is some answers to your queries-
Bloods- she takes thyroxin- low dosage . Last test results were TSH-.9, free T4-18.
All bloods were normal for age and sex.
She was on a holter monitor for 24 hrs.- conclusions were-sinus rhythm with frequent ventricular ectopic so ( including rare couplets and triplets) thought study. There were occasional supra ventricular ectopic so including ten short supra ventricular runs up to 5 secs. long.
ECHCARDIOGRAM FINDINGS- moderate to good quality exam conducted in sinus rhythm with frequent ventricular ectopic beats.
The left ventricle is mildly dilated with normal wall thickness. No evidence of LVOT obstruction. No regional wall motion abnormality. Systolic function is normal with an LVEF of 55% calculated by Simpson's biplane method.
The aortic valve is trileaflet. Normal caliber of the aortic root and ascending aorta. The left atrium is mildly to moderately dilated (28cm).
The mitral valve is morphological lay normal with bowing of the mitral valve leaflets and probable prolapse resulting in grade 2-3 mitral regurgitation. Diastolic function is indeterminate.
The right ventricular size and contractility is within normal limits.
Normal appearance of the pulmonary valve. The right atrium is mildly dilated. Grade 1 tricuspid regurgitation. RSVP 28 mmHg allowing for an RAP +3mmHg
Normal appearance of the atrial septum. No pericardial effusion or intracranial thrombus/mass.
Comment- exam conducted in sinus rhythm with frequent ectopic beats. Mildly dilated left ventricle with normal systolic function (LVEF 55%).
Mild to moderate left and mild right atrial dilatation. Probable mitral valve prolapse with Grade 2-3 regurgitation.
Hope this can shed more light on the problem. One last question- when I researched pacemakers they said they were specifically for arrthymia's. Please comment.
Thank you, Dr. Gillrie
doctor
Answered by Dr. Sagar Makode 1 hour later
Brief Answer:
See the description

Detailed Answer:
Firstly, she is not a candidate for surgery at this stage but she should undergo 6 monthly to yearly echo to monitor ventricular function and severity of MR.
Secondly, Any time in the past she had any episodes suggestive of tia or any embolic manifestation or sudden transient palpitations. Also, have these ectopics disappeared after beta blockers. Atrial ectopics are not life threatening but there are also runs of svt which increases the chances of clot formation in atria and subsequent embolism and risk of stroke. So seeing her holter report she is a candidate for anticoagulation with warfarin. And Atleast aspirin is must in order to reduce the risk of embolism.
Coming to pacemaker, there are two types of device, one which is given for bradycardia without any treatable cause, which is not in our case and secondly ICD which are device which gives shock if patient has life threatening ventricular arrhythmia like sustained ventricular tachycardia or fibrillation. Sustained ventricular tachycardia means, it should persist for atleast 30 sec. They will not be useful in our case as we don't have any of these. So in short, ICD is given for severe arrhythmia and we don't have those, so benefit to risk of ICD do not favor it's use in our patient. So according to guidelines also she is not a candidate. Atleast patient should have one of the above or survivor of cardiac arrest to qualify for ICD.
So at this stage, beta blockers in low dose and if not tolerating then some antiarrhythmic drugs, abstinence from alcohol or stimulants such as caffeine or nicotine, and participation in an exercise program will be the preferred choice for ectopics. So you discuss these issues with local cardiologist, and also of anticoagulation. Hope that helps you and feel free to ask if you have any further doubts.
Above answer was peer-reviewed by : Dr. Remy Koshy
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